Abstract
Background
Left atrial appendage occlusion (LAAO) is indicated for patients with nonvalvular atrial fibrillation at risk of thromboembolic stroke and intolerant to long-term anticoagulation. Standard procedural access for LAAO is from the transfemoral approach. In certain circumstances where this is prohibitive, options are limited.
Case Summary
A patient with atrial fibrillation underwent unsuccessful LAAO due to interrupted inferior vena cava (IVC). She was referred for consideration of LAAO via an alternative access. Using a transhepatic approach, she underwent successful occlusion with a 31-mm Watchman FLX Pro device.
Discussion
Although rare, transfemoral venous approach can be prohibitive for several reasons, including congenitally absent IVC, occluded IVC filter, or extrinsic compression. This case highlights the preprocedural planning, technical approach, and postprocedural considerations for successful LAAO using a transhepatic approach.
Take-Home Message
Alternate access via a transhepatic approach can be a viable alternative for LAAO when the standard femoral venous approach is prohibitive.
Key words: atrial fibrillation, echocardiography, occluder
Visual Summary
Long-term oral anticoagulation remains the cornerstone of management for patients with atrial fibrillation who are at risk of cerebral vascular events due to thromboembolism from the left atrial appendage.1 For those of whom anticoagulation is contraindicated, especially in patients with recurrent bleeding events or those of whom are considered at high bleeding risk, left atrial appendage occlusion (LAAO) can be a viable alternative.2,3 As with many left-sided structural heart procedures, transfemoral venous access remains the standard approach. The right internal jugular (IJ) vein has been proposed as an alternative, and several case reports demonstrate success with mitral transcatheter edge-to-edge repair.4 Recently, this has also been utilized for LAAO with similar results.5 This case illustrates successful LAAO with transhepatic access.
Take-Home Message
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•
Alternate access via a transhepatic approach can be a viable alternative for left atrial appendage occlusion when the standard femoral venous approach is prohibitive.
Case Presentation
An 80-year-old woman with permanent nonvalvular atrial fibrillation (CHA2DS2-VASc score of 7) and multiple episodes of gastrointestinal bleeding without a clear source underwent attempted LAAO via a standard transfemoral venous approach. Following transfemoral venous access, the guidewire could not be advanced beyond the inferior vena cava (IVC) into the right atrium. A standard pigtail catheter was then advanced through the sheath, and a venogram revealed an interrupted IVC (Video 1). She was restarted on anticoagulation and referred to our center for LAAO via an alternative access.
Visual Summary.
Successful Left Atrial Appendage Occlusion Via Transhepatic Approach
Past Medical History
In addition to her permanent nonvalvular atrial fibrillation, her past medical history was also notable for coronary artery disease with remote percutaneous intervention, well-controlled hypertension and hyperlipidemia, peripheral artery disease, and type 2 diabetes.
Investigations
A cardiac-gated computed tomography (CT) completed for preprocedural planning demonstrated a reverse “chicken wing” anatomy measuring 25 × 19 mm at the ostium with a superior trajectory (Figure 1). CT abdomen and pelvis with contrast confirmed an interrupted IVC with a robust azygous vein continuation (Video 2).
Figure 1.
Preprocedural Cardiac-Gated CT
(A to D) Cardiac-gated computed tomography with 3D multiplanar reconstruction with standard aortic (A), mitral (B), and pulmonic (C) views demonstrating a reverse “chicken wing” anatomy with a superior trajectory with (d) ostial measurements of 25 × 19 mm. Adequate depth for either a 31- or 35-mm Watchman FLX Pro.
Management
Due to a failed LAAO via the standard approach, long-term oral anticoagulation was considered, but given her history of recurrent gastro-intestinal bleeding without a clear source, this was not a viable option for the patient. The IJ approach was considered, and there are published case reports using this approach. However, screening cardiac-gated CT suggested a challenging anatomy with respect to maintaining coaxiality to the upgoing ostium with a reverse and superiorly directed “chicken wing.” Following extensive shared decision-making with the patient, a decision was made to pursue LAAO via a transhepatic approach.
Under general anesthesia and transesophageal echocardiography guidance, hepatic vein access was obtained. Using ultrasound guidance, the hepatic vein was cannulated with a micropuncture needle and then upsized to a 6-F × 20-cm side-arm sheath (Figure 2). A venogram was performed to confirm hepatic vein anatomy and communication with the right atrium (Video 3). Using an angled glidewire, a standard 6-F Junkins Right 4 diagnostic catheter was then advanced into the superior vena cava (SVC) and subclavian vein over a J-tipped guidewire. The wire was then exchanged for an Amplatz Extra Stiff guidewire. The sheath was then upsized to a 18-F × 30-cm Checkflo sheath (Cook Medical) (Video 4) with the distal end of the sheath advanced to the SVC. The Amplatz Ex Stiff wire was then exchanged for a steerable Versacross transseptal system. The system was advanced through the previously inserted 18-F sheath, and once the transseptal system was within the SVC, the 18-F sheath was retracted back into the hepatic vein. Next the steerable transseptal sheath was retracted in a standard fashion to perform targeted transseptal puncture at the inferior and posterior regions of the fossa ovalis (Video 5). Once a left atrium rail had been successfully established, the transseptal sheath was removed and exchanged for a TruSteer therapy sheath (Boston Scientific), which was then used to perform an appendogram (Video 6). After standard device preparation, a 31-mm Watchman FLX Pro device was brought into position and deployed in the left atrial appendage. Position and adequate anchoring were confirmed on both transesophageal echocardiography and fluoroscopy. Compression measurements were within range, and there was no device leak noted on color doppler. A final appendogram confirmed only contrast filling through the device fabric (Video 7). The device was released, and the delivery system was retracted back into the right atrium and removed from the body. Through the previously inserted 18-F sheath and a 6-F Junkins Right 4 diagnostic catheter, a standard 0.035-inch J wire was then redirected to the SVC. Next, an 8-mm AMPLATZER vascular plug IV (Abbott Vascular) (Video 8) was deployed in standard fashion, while simultaneously injecting contrast via the 18-F sidearm sheath to ensure positioning within the hepatic vein in proximity to the percutaneous access site. Once the positioning is felt to be in the appropriate location, the standard J wire can be removed, and the vascular plug is released. Before the final withdrawal of the 18-F sheath, 2 gelfoam pledgets were advanced and packed just proximal to the previously deployed vascular plug to close the percutaneous track followed by removal of the sheath (Video 9).
Figure 2.
Micropuncture Guidewire Is Seen Traversing the Hepatic Vein and Into the Right Atrium
Outcome and Follow-Up
The patient did well postprocedurally and was discharged the following day on aspirin and clopidogrel. They were transitioned to aspirin monotherapy after a 3-month cardiac-gated CT showed excellent device position without any peridevice leak or device-related thrombus (Figure 3).
Figure 3.
Follow-Up Cardiac-Gated Computed Tomography Shows a Watchman Device in Excellent Position
Simulated mitral view shown above with evolving appendage closure. No peri-device leak or device-related thrombus noted.
Discussion
As with many left-sided structural heart procedures, the transfemoral venous approach is standard. However, when IVC access is prohibitive (ie, congenitally absent IVC, occluded IVC filter, or extrinsic compression), options for a successful procedure are limited. The transjugular approach has been utilized as an alternative access in multiple case reports of mitral transcatheter edge-to-edge repair with excellent results.4,6 More recently, the transjugular approach for transcatheter tricuspid valve replacement with the Evoque system (Edwards Lifesciences) has also garnered attention, much of which has to do with the unique challenges related to the platform and delivery of the valve.7 Experience with transjugular access for LAAO is much more limited. Case reports have demonstrated some success utilizing the IJ vein, but there are some anatomical and technical challenges with this approach, mainly due to difficulty maintaining coaxiality to the angle of the appendage and the limited maneuverability of the therapy sheath as a result of the acute angulation. The transhepatic approach has also been previously described in several case reports and can be a more favorable alternative, especially for more acutely angled left atrial appendage anatomies, as it is not limited by restricted maneuverability and coaxiality.8, 9, 10, 11, 12, 13, 14 This case demonstrates the importance of preprocedural planning with cardiac-gated CT to help guide optimal transseptal puncture site, sheath selection, and device type and size. In addition, CT imaging of the abdomen/pelvis and/or direct venography can help to understand the heterogenous nature of the hepatic venous system. There are some unique concerns with this approach, mainly with the issue of bleeding, which in rare cases can be fatal. Hepatic vein access should only be performed by interventional radiologists or interventional cardiologists familiar with hepatic vein access and closure strategies. In this case, a combination of vascular plugs and pledgets was used to achieve successful hemostasis. Bleeding may not always be clearly observed as it would with transfemoral or transjugular cases. Specifically, bleeding into the subcapsular space can present with abdominal pain, but bleeding into the peritoneum may not be evident until there is hemodynamic instability. Thus, there is a high index of suspicion for postoperative bleeding complications. Follow-up imaging to assess for hepatic vein patency or occlusion was not performed, which is one of the limitations in this case. Given the paucity of experience with transhepatic access for structural heart interventions, more experience and data are needed to establish clear guidelines on best practices including interval follow-up.
Conclusions
We report a case of failed transfemoral LAAO due to congenitally interrupted IVC who underwent successful LAAO via a transhepatic approach.
Funding Support and Author Disclosures
Dr Pham received honoraria from Abbott Structural Heart. Dr Singh is a consultant and/or an advisory board member to Abbott Structural Heart, Boston Scientific, Siemens Healthcare, and Philips. Dr Rogers is a consultant to Abbott Structural Heart, Boston Scientific, and Siemens Healthcare. Dr Smith is a consultant to Abbott Structural heart. Dr Aman is a consultant to Abbott Structural Heart, Siemens, Philips, and ReValve Solutions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Venogram of Inferior Vena Cava
A venogram of the inferior vena cava (IVC) via a pigtail catheter (white arrow) confirms an interrupted IVC. A large hepatic vein (blue arrow) can be seen with contrast washout suggesting continuity with the right atrium.
Computed Tomography Abdomen and Pelvis
Computed tomography-abdomen and contrast (venous phase) confirms congenitally interrupted inferior vena cava (green arrow) with azygous vein continuation.
Venogram of the Hepatic Vein
Venogram performed with direct contrast injection through the 6-F sidearm sheath into the hepatic vein (white arrow) confirms patency and communication with the right atrium.
Sheath Exchange Over a Stiff Guidewire
Using angled glidewire, a 6-F 100-cm Junkins Right 4 diagnostic catheter was then advanced into the subclavian vein. The glidewire was then exchanged for an Amplatz Ex Stiff guidewire (+). The diagnostic catheter and 6-F sheath were then removed and exchanged for an 18-F × 30-cm Checkflo sheath.
Transseptal Puncture
Through the 18-F sheath, the steerable Versacross transseptal system was advanced into the superior vena cava. The 18-F sheath was then retracted into the hepatic vein. The Versacross sheath was then retracted in standard fashion, and targeted transseptal puncture was then performed along the inferior and posterior fossa ovalis.
Appendogram Through the TruSteer Sheath
Following targeted transseptal puncture and establishment of a rail, the Watchman TruSteer therapy sheath was then advanced over the wire. After removal of dilator and wire, an appendogram was then performed through the TruSteer sheath, confirming size and anatomy seen on preprocedural computed tomography.
Contrast Injection Following Deployment of a 31-mm Watchman FLX Pro
A 31-mm Watchman FLX Pro was then advanced through the TruSteer sheath and deployed in standard fashion with excellent position. After confirming PASS (position, anchor, size, and seal) under transesophageal echocardiography and fluoroscopy, the device was released.
Deployment of Vascular Plug
Deployment of an 8-mm Amplatzer vascular plug IV (∗) device with simultaneous contrast injection through the 18-F sheath to ensure positioning of the closure device in hepatic vein relative to percutaneous access site. After confirming an appropriate position, the vascular plug was then released, and the guidewire was removed.
Deployment of Gelfoam Pledgets
Prior to removal of the sheath, 2 gelfoam pledgets (white arrows) were then advanced through the 18-F sheath to pack the access tract, followed by removal of sheath. Note: radiolucent pledgets not seen on fluoroscopy, but their interaction to the vascular closure device can be observed.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Venogram of Inferior Vena Cava
A venogram of the inferior vena cava (IVC) via a pigtail catheter (white arrow) confirms an interrupted IVC. A large hepatic vein (blue arrow) can be seen with contrast washout suggesting continuity with the right atrium.
Computed Tomography Abdomen and Pelvis
Computed tomography-abdomen and contrast (venous phase) confirms congenitally interrupted inferior vena cava (green arrow) with azygous vein continuation.
Venogram of the Hepatic Vein
Venogram performed with direct contrast injection through the 6-F sidearm sheath into the hepatic vein (white arrow) confirms patency and communication with the right atrium.
Sheath Exchange Over a Stiff Guidewire
Using angled glidewire, a 6-F 100-cm Junkins Right 4 diagnostic catheter was then advanced into the subclavian vein. The glidewire was then exchanged for an Amplatz Ex Stiff guidewire (+). The diagnostic catheter and 6-F sheath were then removed and exchanged for an 18-F × 30-cm Checkflo sheath.
Transseptal Puncture
Through the 18-F sheath, the steerable Versacross transseptal system was advanced into the superior vena cava. The 18-F sheath was then retracted into the hepatic vein. The Versacross sheath was then retracted in standard fashion, and targeted transseptal puncture was then performed along the inferior and posterior fossa ovalis.
Appendogram Through the TruSteer Sheath
Following targeted transseptal puncture and establishment of a rail, the Watchman TruSteer therapy sheath was then advanced over the wire. After removal of dilator and wire, an appendogram was then performed through the TruSteer sheath, confirming size and anatomy seen on preprocedural computed tomography.
Contrast Injection Following Deployment of a 31-mm Watchman FLX Pro
A 31-mm Watchman FLX Pro was then advanced through the TruSteer sheath and deployed in standard fashion with excellent position. After confirming PASS (position, anchor, size, and seal) under transesophageal echocardiography and fluoroscopy, the device was released.
Deployment of Vascular Plug
Deployment of an 8-mm Amplatzer vascular plug IV (∗) device with simultaneous contrast injection through the 18-F sheath to ensure positioning of the closure device in hepatic vein relative to percutaneous access site. After confirming an appropriate position, the vascular plug was then released, and the guidewire was removed.
Deployment of Gelfoam Pledgets
Prior to removal of the sheath, 2 gelfoam pledgets (white arrows) were then advanced through the 18-F sheath to pack the access tract, followed by removal of sheath. Note: radiolucent pledgets not seen on fluoroscopy, but their interaction to the vascular closure device can be observed.